Reimbursement Forms

Below are some of the most frequently requested reimbursement request forms for our HRA/HSA & FSA clients.  Simply click on the form you need to open or download.

Contact Tracy Tirko, Manager TPA and Financial Services,  at 814 289 4229 with any questions.

Medical Deductible Reimbursement Plan Request Form (DOC) (PDF)

HRA Reimbursement Request Form (DOC) (PDF)

FSA Reimbursement Request Form (DOC) (PDF)